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Balance billing prohibition data call index page

Balance billing prohibition report

On a quarterly basis, health benefit plan issuers shall submit certain data to the department concerning balance billing. This data covers the following:

  • Billed amounts
  • Amounts paid to providers that are out-of-network and in-network
  • The number of in-network providers
  • The number of network terminations initiated
  • Mediation requests and disputes settled
  • Licensing board complaints, investigations, and sanctions

Balance billing prohibition data call

Data is collected on a quarterly basis. Second quarter report will be due on August 1, 2022.

Background information

Collection and reporting of this data is required by Insurance Code 38.004.

Reporting form

Health plan issuers 2022 Q3 reporting form

Licensing board 2022 Q3 reporting form

Due Dates

Quarterly reports will be due according to the following schedule:

Start End Due Date
Q1 January 1 March 31 May 1
Q2 April 1 June 30 August 1
Q3 July 1 September 30 November 1
Q4 October 1 December 31 February 1


FAQ

Which health plans are required to report?
Health benefit plans subject to Insurance Code Chapter 1467 are required to report. This includes health benefit plans offered by HMOs, PPOs, and EPOs, as well as some health plan administrators.

How much data will be required each quarter?
The very first report due August 1, 2020 will collect data from the previous six quarters. Each subsequent report will collect data from the preceding quarter.

Does this data call apply to Medicaid/CHIP health plans?
No. Only issuers of commercial comprehensive health coverage are required to report.

Should denied and rejected claims be included in the report?
No. Claims that are denied or rejected should be excluded from submissions.

Do we include payments made by enrollees in ‘Total amounts paid’ to providers?
No, only report the amount paid to the provider by the health plan.

How are out-of-network providers defined?
For the purposes of this report, any provider that hasn’t contracted with the plan should be considered out-of-network.

Do we include claims from out-of-state providers in our submission?
Yes. Please report data for all covered services under the plan, even if they were performed by out-of-state providers.

How should non-emergency ambulance service be reported?
If air ambulance or ground ambulance was provided for a service that was neither emergency nor other listed service type, please exclude it.

How do we decide how to categorize amounts in situations where we are unable to determine which column(s) to use for reporting?
Since lab and diagnostic services are often a subset of facility services, services should first be classified as lab or diagnostic if applicable. Any remaining services can then be classified as facility-based (non-emergency) or emergency. If a visit consists of both emergency care and a hospital admission, and if you are unable to split the claim between those two types, please classify it according to which type made up the largest portion of the claim.

How are the mediation and arbitration averages to be calculated?
For mediation and arbitration sections, please report the averages per dispute.

How do we report data for arbitration/mediation cases that span more than one quarter?
Please report each component of the arbitration and mediation data based on the quarter in which it becomes known. A claim might occur in one quarter, while an arbitration or mediation request related to that claim might be reported in another quarter, and the corresponding dispute settlement or civil action might be reported in yet a different quarter. While this approach won’t allow us to compute statistics such as settlement rates, it will still allow us to look at overall trends to assess the impact of balance billing prohibition under SB 1264. This approach is more practical than trying to align numerous claims with their disputes and outcomes where the process spans more than one quarter.

Should the average settlement amount for arbitration and mediation include the amounts settled by teleconference?
The average settlement amount reported should be the average for all settlements, including those settled by teleconference as well as those settled through arbitration/mediation.

Where do we send completed reports?
Once the MS Excel reporting form is completed, it should be sent as an email attachment to HealthData@tdi.texas.gov.

For more information, contact: HealthData@tdi.texas.gov

Last updated: 9/27/2022